10/13/2014 PTSD as a Shame Disorder (A Work in Progress) Judith L. Herman, M.D. ISTSS Webinar, October 2014 jherman@challiance.org Characteristics of Shame: A Biological and Social “Signal” • Rapid and overwhelming (“fast - track”) physiologic response • Characteristic facial and postural signs • Similar to submissive appeasement displays of social animals (Keltner & Harker, 1998) • Recognized across cultures (Izard, 1971) • Functions to preserve social bonds Facial and Postural Signs of Shame • Gaze Aversion (down) • Blushing • Lip corners down, lips sucked in • Head down, shoulders slumped • Hiding face 1
10/13/2014 The Posture of Shame The Subjective Experience of Shame 1: Shame as a Self-Conscious Experience • Shock and flooding with painful emotion • Loss of language • “Doubling” of self, experiencing and observing simultaneously • Feeling small, ridiculous, exposed, etc. • Wish to hide (“sink through the floor, crawl in a hole and die”) Shame v. Guilt (Tangney, 1995; Lewis,1987) • Focus on global self • Focus on specific action • Self “split” • Self unified • Feeling small • Feeling sorry • Self passive • Self active • Painful emotion • May feel little emotion • Desire to hide, escape or • Desire to confess, strike back (“shame - rage”) apologize, make amends • Discharge in shared • Discharge in act of good-humored laughter reparation 2
10/13/2014 The Physiology of Shame The brake of arousal seen in shame (reflected in cardiac deceleration, switch in mood, gaze aversion, and blushing) reflects a sudden dynamic switch from sympathetic- dominant to parasympathetic-dominant ANS activity…The replacement of parasympathetic passive for sympathetic active coping processes is reflected in the common shame experience of helplessness. --Allan Schore: Affect Regulation and the Repair of the Self (2003) The Relational Origins of Shame States of shame and pride…involve a relationship between the self and an internalized other in whose eyes one is proud or ashamed. People who look in a mirror with pleasure at their own reflection are summoning the “mutual delight” of an internalized affectionate interaction. When they look at themselves with shame, people are also mourning a lost “mutual delight,” in which the internalized other is still beloved, only the self is hated. --- Helen Block Lewis, Shame and Guilt in Human Nature (1987) Forms of Intersubjectivity 3
10/13/2014 Developmental Origins of Shame • Characteristic Signs at 12-18 Months • Erikson : Autonomy v. Shame and Doubt • Developmental Task: Self-Regulation • Regulation of Body, Affect, Desire and Will in Attunement with Others. • Positive Resolution: Self-Respect and Respect for Others (Mutuality) The Developmental Origins of Shame 2: Focus on Reunion Interactions The returning toddler, eagerly looking forward to maternal recognition, is suddenly confronted with noncooperation, communicated visually not only in the absence of the smile of contact, but also in the presence of the mother’s “strange face,” a physical expression denoting her negative emotional state … The shock of shame results from the violation of the infant’s expectation of affective attunement . ---Allan Schore: Affect Regulation and the Repair of the Self (2003) Normal Development of Shame Regulation In the shame transaction, there is a break of attachment …between the toddler and caregiver. However, the sequence…is not quite completed ---the pair may attempt to resynchronize. The infant’s averted gaze…has been shown to be a potent elicitor of attention from mothers of securely attached infants, but not from those of insecurely attached infants. The nature of the caregiver’s response (or lack of it) at this point is critical to… shame recovery and the subsequent evolution of an internalized mechanism to regulate shame states. ----Schore (2003). 4
10/13/2014 Development of Chronic Shame States Repeated early failures of attunement create a belief that one’s affective needs generally are unacceptable and shameful…The inner experience of the affect of shame therefore becomes associated with a painful, self-disorganizing internal state that cannot be regulated. ----Schore (2003) Shame Spirals: Shame-Shame and Shame-Rage Feeling Ashamed Feeling Ashamed Humiliated Fury Feeling Ashamed Wish to Retaliate of Feeling Ashamed Shame For Shame and Guilt “Overreaction” For “Overreaction” Development of Chronic Shame States Why should the brutalization of affectional bonds be associated with such an intense and destructive sense of self- disgust, verging on self-hatred? The shame concerns being treated as a physical object in the very context where special personal recognition is expected. ---Fonagy et. al, 2003 5
10/13/2014 The Family of Shame Emotions: Everyday v. Catastrophic Shame • Humiliation • Shyness • Self-Loathing • Self- • Defilement Consciousness • Embarrassment • Disgrace • Feeling • Feeling Ridiculous Dishonored The Subjective Experience of Shame: 2 Shame is one’s own vicarious experience of the other’s scorn. The self-in-the eyes-of-the-other is the focus of awareness… The experience of shame often occurs in the form of imagery, of looking or being looked at. Shame may also be played out as an internal colloquy, in which the whole self is condemned. --Helen Block Lewis, 1987 The Social Role of Shame The role of shame in regulating distance may be a key to understanding all social relationships. If one comes too close to us, we feel invaded or exposed, a shame state; if one stays too far from us, we feel rejected or invisible, another shame state. -------Scheff and Retzinger (1997). 6
10/13/2014 The Social Role of Shame: 2 • Shame mediates attunement to indices of social value or status • High sensitivity to “slights” or “losing face” • Relations of dominance/subordination inherently shaming Methods of Domination • Violence and Threat of Violence • Control of Bodily Functions • Capricious Enforcement of Petty Rules • Intermittent Rewards • Isolation • Degradation • Enforced Participation in Atrocities ----Amnesty International: Report on Torture, 1973 Shame and Dissociation Talbot and Talbot, 2004 (N=99 Inpatients) 30 25 20 Mean DES 15 High Shame Score Low Shame 10 5 0 Abused Women Control Group 7
10/13/2014 Shame and PTSD (Andrews et al, 2000) N=157 • Victims interviewed 1 & 6 mo. post crime • Shame at 1 mo. predicted PTSD at 6 mo • Content of shame responses: • Feelings of defeat (failure to take effective action) • Feeling exposed in eyes of others • Feeling ashamed of emotional reactions • Feelings of humiliation Shame and Suicidality (Dutra, Callahan, Forman, Mendelsohn & Herman, 2008) N=137 Outpatients • Shame measured by self-report (Young Schema Questionnaire) • Shame/Defectiveness schema highly correlated with: ** PTSD (p<.01) *** Dissociation (p<.001) ** Suicidal Ideation (p<.01) ** Suicide Plan (p <.01) * Recent suicide attempt (p<.05) The Analysis of Shame Adopting the viewpoint that shame is a normal state which accompanies the breaking of affectional bonds allows shame to take its place as a universal, normal human state of being. Analyzing shame reactions in an atmosphere in which their natural function is taken for granted makes analytic work considerably easier. ----- Helen Block Lewis (1981) 8
10/13/2014 Recognizing Shame: Paralinguistic Cues (Retzinger, 1995) • Vocal withdrawal, confusion of thought • Hesitation, self interruption (censorship) soft speech, mumbling • Silences, stammering, fragmented speech • Many filled pauses (-uh-), long pauses • Rapid speech, condensed words incoherence, tensely laughed words. Recognizing Shame: Visual Cues • Hiding behavior such as the hand or hair covering all or parts of the face • Gaze aversion, eyes downcast or averted • Hanging head, hunching shoulders • Squirming, fidgeting • Blushing • Overcontrol, such as turning in, biting, or licking the lips, biting the tongue • false smiling (Ekman & Freisen, 1982); or other masking behaviors. Resolution of Shame in Groups People have at once a sense of their own honour and a respect for other people’s honour; they can feel indignation or other forms of anger when honour is violated, in their own case or someone else’s. These are shared sentiments, and they serve to bind people together in a community of feeling. ----Bernard Williams Shame and Necessity , 1993 9
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